CADRES RÉSERVÉS A...

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Contrôle du Livret d’Information Patient Rubriques complétées et/ou signées : OUI NON (Rubriques soulignées obligatoires) Identification du patient (verso couverture) Patient Identification Autorité parentale pour patient mineur (p. 2) Holder(s) of parental responsibility for a patient who is a minor Consentement éclairé chirurgical (p. 4) Informed consent for anaesthesia surgery Consentement éclairé anesthésique (p. 4) Informed consent for anaesthesia Evaluation risque ATNC (p. 5) Evaluation of risks related to prions Questionnaire anesthésie (p. 10 à 13) Anaesthesia questionnaire Autorisations du patient (p. 18) Authorisations Patient Information Booklet Before a surgical procedure and/or a procedure under anaesthesia PART OF YOUR MEDICAL RECORD PRE-ANAESTHESIA CONSULTATION Please present yourself at the main reception desk before your appointment. On ............................(date) at.......................(time) If your pre-anaesthesia consultation has not yet been arranged by your doctor or his or her secretary, please call this number as soon as possible : 04 91 18 65 33 ATTENTION ! This booklet must be completed and presented together with the following documents : Valid proof of identification, such as your passport Your UP-TO-DATE national health insurance card (e.g. Carte vitale or equivalent) Your complementary health insurance card or coverage agreement if you have complementary health insurance Your current prescriptions and medicines if you are taking medication The results of any additional medical tests (e.g. laboratory tests, X-rays, scans, electrocardio- gram, etc.) Your blood group card, if you have one. In addition to the above documents, if the PATIENT is a MINOR, the following documents must also be presented : Valid proof of identification, such as a passport, for the holder(s) of parental responsibility Your family register (livret de famille) The patient’s child health record and vaccination card. This booklet will be inserted into your patient file. Hôpital Privé Marseille - Vert Coteau 96 Avenue des Caillols - 13012 MARSEILLE Tél : 04 91 18 68 68 - Fax : 04 91 18 65 27 hpm-vert-coteau.fr Contrôle N°1 : Service Consultations NOM : ............................................................. SIGNATURE : Contrôle N°2 : Secrétaire Pré-admission NOM : ............................................................. SIGNATURE : Contrôle N°3 : IDE du Service de Soins NOM : .............................................................. SIGNATURE : Contrôle N°1 : Service Planification NOM : ............................................................. SIGNATURE : CADRES RÉSERVÉS A L’ETABLISSEMENT

Transcript of CADRES RÉSERVÉS A...

Page 1: CADRES RÉSERVÉS A L’ETABLISSEMENThpm-vert-coteau.fr/fichiers/1523982069-hpmv_m_2002_lip_anglais... · Contrôle du Livret d’Information Patient Rubriques complétées et/ou

Contrôle du Livret d’Information Patient

Rubriques complétées et/ou signées : OUI NON (Rubriques soulignées obligatoires)

• Identification du patient (verso couverture) � � Patient Identification

• Autorité parentale pour patient mineur (p. 2) � �

Holder(s) of parental responsibility for a patient who is a minor

• Consentement éclairé chirurgical (p. 4) � �

Informed consent for anaesthesia surgery

• Consentement éclairé anesthésique (p. 4) � �

Informed consent for anaesthesia

• Evaluation risque ATNC (p. 5) � �

Evaluation of risks related to prions

• Questionnaire anesthésie (p. 10 à 13) � �

Anaesthesia questionnaire

• Autorisations du patient (p. 18) � �

Authorisations

Patient Information Booklet Before a surgical procedure and/or a procedure under anaesthesia

PART OF YOUR MEDICAL RECORD

PRE-ANAESTHESIA CONSULTATION Please present yourself at the main reception desk before your appointment.

On ............................(date) at.......................(time)

If your pre-anaesthesia consultation has not yet been arranged by your doctor or his or her secretary,

please call this number as soon as possible : 04 91 18 65 33

ATTENTION !

This booklet must be completed and presented together with the following documents :

• Valid proof of identification, such as your passport

• Your UP-TO-DATE national health insurance card (e.g. Carte vitale or equivalent)

• Your complementary health insurance card or coverage agreement if you have complementary

health insurance

• Your current prescriptions and medicines if you are taking medication

• The results of any additional medical tests (e.g. laboratory tests, X-rays, scans, electrocardio-

gram, etc.)

• Your blood group card, if you have one.

In addition to the above documents, if the PATIENT is a MINOR, the following documents must also be presented :

• Valid proof of identification, such as a passport, for the holder(s) of parental responsibility

• Your family register (livret de famille)

• The patient’s child health record and vaccination card.

This booklet will be inserted into your patient file.

Hôpital Privé Marseille - Vert Coteau 96 Avenue des Caillols - 13012 MARSEILLE

Tél : 04 91 18 68 68 - Fax : 04 91 18 65 27 hpm-vert-coteau.fr

Contrôle N°1 : Service Consultations

NOM : ............................................................. SIGNATURE :

Contrôle N°2 : Secrétaire Pré-admission

NOM : ............................................................. SIGNATURE :

Contrôle N°3 : IDE du Service de Soins

NOM : .............................................................. SIGNATURE :

Contrôle N°1 : Service Planification

NOM : ............................................................. SIGNATURE :

CADRES RÉSERVÉS A L’ETABLISSEMENT

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Surname at birth ............................................................................

Married name ................................................................................

First name ...................................................................................

Date of birth .................................................................................

Occupation ...................................................................................

Address ......................................................................................

................................................................................................

Postcode ................................. City/town ...................................

Telephone ................................ Mobile phone ..............................

Email address ................................................................................

For administrative use

Etiquette Patient

Patient Identification

Identitovigilance” is an initiative that seeks to monitor and manage risks and errors related to the identification of patients during the administrative processing of their files and throughout their course of treatment in the health care facility. In accordance with Instruction no. DGOS/MSIOS/2013/281 of 7 June 2013 on the use of family names (or surnames at birth) to identify patients in the information systems of health care facilities, we shall identify you during your hos-pitalisation using your surname at birth. When you are admitted to the ward, you will be given an identification bracelet. Please make sure you wear it during your whole stay in the hospital.

Article L162-21 of the French Social Security Code (Code de la Sécurité Sociale): “(…) In these health care facilities, for the provision of medical care, an insured person may be asked to confirm his or her iden-

tity to the administrative services by presenting an identity document with his or her photograph on it.”

The V2010 accreditation handbook (manuel de certification) from the French National Authority for Health (HAS), crite-rion 15a : “Before any therapeutic or diagnostic procedure is carried out, health care professionals must verify that the identity

of the person undergoing the procedure matches the identity indicated on the prescription”.

Date prévue d’intervention : ..................................................................................................... Date et heure prévues d’hospitalisation : ................................................................................

Clinique du Golfe de Saint-Tropez

Pôle de Santé du Golfe RD 559 - RP Général D. Brosset 83580 GASSIN Tél : 04 98 12 70 00 Fax : 04 98 12 70 04

clinique-golfe-saint-tropez.fr

Hôpital Privé Toulon Hyères

Sainte Marguerite

Avenue Alexis Godillot 83400 HYERES Tél : 04 94 12 85 85 Fax : 04 94 12 55 67

hpth-sainte-marguerite.fr

Saint Jean

Avenue Georges Bizet 83000 TOULON Tél : 04 94 16 30 30 Fax : 04 94 16 30 58

hpth-saint-jean.fr

Saint Roch

99 avenue Saint-Roch 83000 TOULON Tél : 04 94 18 89 00 Fax : 04 94 18 89 23

hpth-saint-roch.fr

Clinique de La Ciotat

Boulevard Lamartine 13600 LA CIOTAT Tél : 0 826 20 75 80 Fax : 04 42 08 73 44

www.clinique-de-la-ciotat.fr

Hôpital Privé Marseille

Vert Coteau

96, Avenue des Caillols 13012 MARSEILLE Tél : 04 91 18 68 68 Fax : 04 91 18 65 27

hpm-vert-coteau.fr

Beauregard

23, Rue des Linots - 13012 MARSEILLE Tél : 0 825 74 34 34 Fax : 04 91 12 10 15

hpm-beauregard.fr

Soins Assistance Le Plein Ouest Bät C - 1, Rue Albert Cohen

13016 MARSEILLE Tél : 04 96 20 66 66

www.soins-assistance.org

Association de Dialyse Varoise

A.DI.VA

Centre de La Seyne

Avenue Jules Renard 83500 La Seyne sur Mer

Tél. : 04 98 00 25 36 Fax : 04 98 00 25 35 www.association-dialyse-varoise.fr

Centre de Toulon

Hôpital Privé Toulon Hyères – Saint Jean 1 avenue Georges Bizet

83000 TOULON Tel : 04 94 16 67 67 Fax : 04 94 16 67 68

www.association-dialyse-varoise.fr

Centre de Gassin

Espace Santé Gassin Quartier Saint-Martin - D559

83580 GASSIN Tél. : 04 94 43 39 03 Fax : 04 94 43 39 05

www.association-dialyse-varoise.fr

Les Établissements Sainte Marguerite